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PERSPECTIVES IN BIOLOGY AND MEDICINE Volume 31 ¦ Number 2 ¦ Winter 1988 EDITORIAL: THE LANGUAGE OF THE MARKETPLACE AND THE LANGUAGE OF MEDICAL CARE The changing economic and institutional context for medical care in the United States is a matter of extensive comment and research. One can read Paul Starr's The Social Transformation of American Medicine [1] with intellectual profit, attend to the final paragraphs, and move on from there in a trajectory he anticipated. Perhaps not noted as much is the clash of languages, symbols, and concepts used by the efficient managers of health care on the one hand and by physicians and other persons involved in care on the other. The differences in language reflect differences in perspectives—indeed, differences in perception of the vocation of those committed to health care. It is our conviction that how we speak about health care reflects our perceptions of its most important functions and aspects. If we speak about it primarily in terms of the marketplace, that terminology will affect how we think about physicians, nurses, patients, and other people and aspects of the profession. For example, at a meeting of the board of a profitable not-for-profit health system a presentation was made by an upper-level manager in which the board was instructed that each hospital in the system should have "a lead product line," that is, oncology, psychiatry, gynecology, and so forth. Similarly, the senior executive of the hospital of a major medical school was heard to say, "This year we are marketing heart disease and cancer." If medical services become product lines, physicians become producers ofmarketable services, and patients become consumers. Medical care becomes a series of transactions. Such language, and the perceptions it reflects, radically alters the traditional perceptions and motivations of those committed to caring for ill persons. For another example, ajournai for hospital administrators featured in bold type a quotation from an article. It read, "Administrators should Perspectives in Biology and Medicine, 31, 2 ¦ Winter 1988 \ 157 learn to treat the medical staffas human capital for the efficient management of the hospital." Physicians become "human capital" and not persons committed to the relief of human suffering; such is the radical alteration of traditional perceptions. One may safely predict that the consequences of the management techniques symbolized by this language will be as catastrophic for medicine as it turned out to be for the American automobile industry. Halberstam's detailed story [2] of the decline of this great industry clearly ascribes the debacle to domination of decision making by the financial managers; the innovative engineers and product men lost their influence. The finance managers took over the businesses because "They knew first and foremost how to keep their superiors happy. They understood the bottom line, and they understood how to find the weakness in any proposal. They did not really know cars, but they knew the language of the company. They were particularly good at putting the product men on the defensive. They were great counter-punchers. They never had to suggest or create, only to show the fault in others. They never stood for anything. They had no record." Top managers were indifferent to the poor quality of their products. They failed to fully understand why the public was not buying their cars until informed by a large auto rental firm that American cars did not measure up to those made in Japan or Germany. In medicine, the dominating language is becoming "cost effective." The health maintenance organizations (HMOs), which are most cost effective, place administrative brakes on procedures ordered by physicians and provide bonuses to physicians for not overspending of their time or procedures. In fee-for-service practice, physicians are now sometimes forced to create diagnoses in order to satisfy third-party payers. Periodic examinations (an aspect of preventive medicine) and an undiagnosable malaise just will not do for reimbursement. When ill, the patient seldom cares that a special diagnostic procedure is not statistically likely to define his problem; he wants it if there is a chance that it will be helpful. In this connection it has been pointed out elsewhere [3] that an immense proportion of physicians' effort is spent...


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